Medical Policy Anti-CCP Testing for Rheumatoid Arthritis

Medical Policy Anti-CCP Testing for Rheumatoid Arthritis Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 142 BCBSA Reference Number: 2.01.78 Related Policies None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO Blue SM and Medicare PPO Blue SM Members Measurement of anti-ccp, when used as part of the diagnostic workup for rheumatoid arthritis, may be considered MEDICALLY NECESSARY. Measurement of anti-ccp, when used to monitor disease activity and/or treatment response, is INVESTIGATIONAL. Prior Authorization Information Commercial Members: Managed Care (HMO and POS) Prior authorization is NOT required. Commercial Members: PPO, and Indemnity Prior authorization is NOT required. Medicare Members: HMO Blue SM Prior authorization is NOT required. Medicare Members: PPO Blue SM Prior authorization is NOT required. CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference. 1

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT codes CPT codes: Code Description 86200 Cyclic citrullinated peptide (CCP), antibody ICD-9 Diagnosis Codes ICD-9-CM diagnosis codes: Code Description 714.0 Rheumatoid arthritis 714.1 Felty's syndrome 714.2 Other rheumatoid arthritis with visceral or systemic 714.30 Polyarticular juvenile rheumatoid arthritis, chronic or unspecified 714.31 Polyarticular juvenile rheumatoid arthritis, acute 714.32 Pauciarticular juvenile rheumatoid arthritis 714.33 Monoarticular juvenile rheumatoid arthritis ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description M05.40 Rheumatoid myopathy with rheumatoid arthritis of unspecified site M05.00 Felty's syndrome, unspecified site M05.011 Felty's syndrome, right shoulder M05.012 Felty's syndrome, left shoulder M05.019 Felty's syndrome, unspecified shoulder M05.021 Felty's syndrome, right elbow M05.022 Felty's syndrome, left elbow M05.029 Felty's syndrome, unspecified elbow M05.031 Felty's syndrome, right wrist M05.032 Felty's syndrome, left wrist M05.039 Felty's syndrome, unspecified wrist M05.041 Felty's syndrome, right hand M05.042 Felty's syndrome, left hand M05.049 Felty's syndrome, unspecified hand M05.051 Felty's syndrome, right hip M05.052 Felty's syndrome, left hip M05.059 Felty's syndrome, unspecified hip M05.061 Felty's syndrome, right knee M05.062 Felty's syndrome, left knee M05.069 Felty's syndrome, unspecified knee M05.071 Felty's syndrome, right ankle and foot M05.072 Felty's syndrome, left ankle and foot M05.079 Felty's syndrome, unspecified ankle and foot M05.09 Felty's syndrome, multiple sites M05.20 Rheumatoid vasculitis with rheumatoid arthritis of unspecified site M05.211 Rheumatoid vasculitis with rheumatoid arthritis of right shoulder M05.212 Rheumatoid vasculitis with rheumatoid arthritis of left shoulder M05.219 Rheumatoid vasculitis with rheumatoid arthritis of unspecified shoulder 2

M05.221 Rheumatoid vasculitis with rheumatoid arthritis of right elbow M05.222 Rheumatoid vasculitis with rheumatoid arthritis of left elbow M05.229 Rheumatoid vasculitis with rheumatoid arthritis of unspecified elbow M05.231 Rheumatoid vasculitis with rheumatoid arthritis of right wrist M05.232 Rheumatoid vasculitis with rheumatoid arthritis of left wrist M05.239 Rheumatoid vasculitis with rheumatoid arthritis of unspecified wrist M05.241 Rheumatoid vasculitis with rheumatoid arthritis of right hand M05.242 Rheumatoid vasculitis with rheumatoid arthritis of left hand M05.249 Rheumatoid vasculitis with rheumatoid arthritis of unspecified hand M05.251 Rheumatoid vasculitis with rheumatoid arthritis of right hip M05.252 Rheumatoid vasculitis with rheumatoid arthritis of left hip M05.259 Rheumatoid vasculitis with rheumatoid arthritis of unspecified hip M05.261 Rheumatoid vasculitis with rheumatoid arthritis of right knee M05.262 Rheumatoid vasculitis with rheumatoid arthritis of left knee M05.269 Rheumatoid vasculitis with rheumatoid arthritis of unspecified knee M05.271 Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot M05.272 Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot M05.279 Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot M05.29 Rheumatoid vasculitis with rheumatoid arthritis of multiple sites M05.30 Rheumatoid heart disease with rheumatoid arthritis of unspecified site M05.311 Rheumatoid heart disease with rheumatoid arthritis of right shoulder M05.312 Rheumatoid heart disease with rheumatoid arthritis of left shoulder M05.319 Rheumatoid heart disease with rheumatoid arthritis of unspecified shoulder M05.321 Rheumatoid heart disease with rheumatoid arthritis of right elbow M05.322 Rheumatoid heart disease with rheumatoid arthritis of left elbow M05.329 Rheumatoid heart disease with rheumatoid arthritis of unspecified elbow M05.331 Rheumatoid heart disease with rheumatoid arthritis of right wrist M05.332 Rheumatoid heart disease with rheumatoid arthritis of left wrist M05.339 Rheumatoid heart disease with rheumatoid arthritis of unspecified wrist M05.341 Rheumatoid heart disease with rheumatoid arthritis of right hand M05.342 Rheumatoid heart disease with rheumatoid arthritis of left hand M05.349 Rheumatoid heart disease with rheumatoid arthritis of unspecified hand M05.351 Rheumatoid heart disease with rheumatoid arthritis of right hip M05.352 Rheumatoid heart disease with rheumatoid arthritis of left hip M05.359 Rheumatoid heart disease with rheumatoid arthritis of unspecified hip M05.361 Rheumatoid heart disease with rheumatoid arthritis of right knee M05.362 Rheumatoid heart disease with rheumatoid arthritis of left knee M05.369 Rheumatoid heart disease with rheumatoid arthritis of unspecified knee M05.371 Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot M05.372 Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot M05.379 Rheumatoid heart disease with rheumatoid arthritis of unspecified ankle and foot M05.39 Rheumatoid heart disease with rheumatoid arthritis of multiple sites M05.411 Rheumatoid myopathy with rheumatoid arthritis of right shoulder M05.412 Rheumatoid myopathy with rheumatoid arthritis of left shoulder M05.419 Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder M05.421 Rheumatoid myopathy with rheumatoid arthritis of right elbow M05.422 Rheumatoid myopathy with rheumatoid arthritis of left elbow M05.429 Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow M05.431 Rheumatoid myopathy with rheumatoid arthritis of right wrist M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist M05.439 Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist 3

M05.441 Rheumatoid myopathy with rheumatoid arthritis of right hand M05.442 Rheumatoid myopathy with rheumatoid arthritis of left hand M05.449 Rheumatoid myopathy with rheumatoid arthritis of unspecified hand M05.451 Rheumatoid myopathy with rheumatoid arthritis of right hip M05.452 Rheumatoid myopathy with rheumatoid arthritis of left hip M05.459 Rheumatoid myopathy with rheumatoid arthritis of unspecified hip M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee M05.469 Rheumatoid myopathy with rheumatoid arthritis of unspecified knee M05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot M05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot M05.479 Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites M05.50 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site M05.511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder M05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder M05.519 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder M05.521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow M05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow M05.529 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow M05.531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist M05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist M05.539 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist M05.541 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand M05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of left hand M05.549 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand M05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip M05.559 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee M05.569 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot M05.579 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites M05.60 Rheumatoid arthritis of unspecified site with of other organs and systems M05.611 Rheumatoid arthritis of right shoulder with of other organs and systems M05.612 Rheumatoid arthritis of left shoulder with of other organs and systems M05.619 Rheumatoid arthritis of unspecified shoulder with of other organs and systems M05.621 Rheumatoid arthritis of right elbow with of other organs and systems M05.622 Rheumatoid arthritis of left elbow with of other organs and systems M05.629 Rheumatoid arthritis of unspecified elbow with of other organs and systems M05.631 Rheumatoid arthritis of right wrist with of other organs and systems M05.632 Rheumatoid arthritis of left wrist with of other organs and systems M05.639 Rheumatoid arthritis of unspecified wrist with of other organs and systems M05.641 Rheumatoid arthritis of right hand with of other organs and systems M05.642 Rheumatoid arthritis of left hand with of other organs and systems M05.649 Rheumatoid arthritis of unspecified hand with of other organs and systems 4

M05.651 Rheumatoid arthritis of right hip with of other organs and systems M05.652 Rheumatoid arthritis of left hip with of other organs and systems M05.659 Rheumatoid arthritis of unspecified hip with of other organs and systems M05.661 Rheumatoid arthritis of right knee with of other organs and systems M05.662 Rheumatoid arthritis of left knee with of other organs and systems M05.669 Rheumatoid arthritis of unspecified knee with of other organs and systems M05.671 Rheumatoid arthritis of right ankle and foot with of other organs and systems M05.672 Rheumatoid arthritis of left ankle and foot with of other organs and systems M05.679 Rheumatoid arthritis of unspecified ankle and foot with of other organs and systems M05.69 Rheumatoid arthritis of multiple sites with of other organs and systems M05.70 Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems M05.711 Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems M05.712 Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems M05.719 Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems M05.721 Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems M05.722 Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems M05.729 Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems M05.731 Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems M05.732 Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems M05.739 Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems M05.741 Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems M05.742 Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems M05.749 Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems M05.751 Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems M05.752 Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems M05.759 Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems M05.769 Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or 5

systems M05.779 Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems M05.80 Other rheumatoid arthritis with rheumatoid factor of unspecified site M05.811 Other rheumatoid arthritis with rheumatoid factor of right shoulder M05.812 Other rheumatoid arthritis with rheumatoid factor of left shoulder M05.819 Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder M05.821 Other rheumatoid arthritis with rheumatoid factor of right elbow M05.822 Other rheumatoid arthritis with rheumatoid factor of left elbow M05.829 Other rheumatoid arthritis with rheumatoid factor of unspecified elbow M05.831 Other rheumatoid arthritis with rheumatoid factor of right wrist M05.832 Other rheumatoid arthritis with rheumatoid factor of left wrist M05.839 Other rheumatoid arthritis with rheumatoid factor of unspecified wrist M05.841 Other rheumatoid arthritis with rheumatoid factor of right hand M05.842 Other rheumatoid arthritis with rheumatoid factor of left hand M05.849 Other rheumatoid arthritis with rheumatoid factor of unspecified hand M05.851 Other rheumatoid arthritis with rheumatoid factor of right hip M05.852 Other rheumatoid arthritis with rheumatoid factor of left hip M05.859 Other rheumatoid arthritis with rheumatoid factor of unspecified hip M05.861 Other rheumatoid arthritis with rheumatoid factor of right knee M05.862 Other rheumatoid arthritis with rheumatoid factor of left knee M05.869 Other rheumatoid arthritis with rheumatoid factor of unspecified knee M05.871 Other rheumatoid arthritis with rheumatoid factor of right ankle and foot M05.872 Other rheumatoid arthritis with rheumatoid factor of left ankle and foot M05.879 Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified M06.00 Rheumatoid arthritis without rheumatoid factor, unspecified site M06.011 Rheumatoid arthritis without rheumatoid factor, right shoulder M06.012 Rheumatoid arthritis without rheumatoid factor, left shoulder M06.019 Rheumatoid arthritis without rheumatoid factor, unspecified shoulder M06.021 Rheumatoid arthritis without rheumatoid factor, right elbow M06.022 Rheumatoid arthritis without rheumatoid factor, left elbow M06.029 Rheumatoid arthritis without rheumatoid factor, unspecified elbow M06.031 Rheumatoid arthritis without rheumatoid factor, right wrist M06.032 Rheumatoid arthritis without rheumatoid factor, left wrist M06.039 Rheumatoid arthritis without rheumatoid factor, unspecified wrist M06.041 Rheumatoid arthritis without rheumatoid factor, right hand M06.042 Rheumatoid arthritis without rheumatoid factor, left hand M06.049 Rheumatoid arthritis without rheumatoid factor, unspecified hand M06.051 Rheumatoid arthritis without rheumatoid factor, right hip M06.052 Rheumatoid arthritis without rheumatoid factor, left hip M06.059 Rheumatoid arthritis without rheumatoid factor, unspecified hip M06.061 Rheumatoid arthritis without rheumatoid factor, right knee M06.062 Rheumatoid arthritis without rheumatoid factor, left knee M06.069 Rheumatoid arthritis without rheumatoid factor, unspecified knee M06.071 Rheumatoid arthritis without rheumatoid factor, right ankle and foot M06.072 Rheumatoid arthritis without rheumatoid factor, left ankle and foot M06.079 Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot 6

M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites M06.1 Adult-onset Still's disease M06.80 Other specified rheumatoid arthritis, unspecified site M06.811 Other specified rheumatoid arthritis, right shoulder M06.812 Other specified rheumatoid arthritis, left shoulder M06.819 Other specified rheumatoid arthritis, unspecified shoulder M06.821 Other specified rheumatoid arthritis, right elbow M06.822 Other specified rheumatoid arthritis, left elbow M06.829 Other specified rheumatoid arthritis, unspecified elbow M06.831 Other specified rheumatoid arthritis, right wrist M06.832 Other specified rheumatoid arthritis, left wrist M06.839 Other specified rheumatoid arthritis, unspecified wrist M06.841 Other specified rheumatoid arthritis, right hand M06.842 Other specified rheumatoid arthritis, left hand M06.849 Other specified rheumatoid arthritis, unspecified hand M06.851 Other specified rheumatoid arthritis, right hip M06.852 Other specified rheumatoid arthritis, left hip M06.859 Other specified rheumatoid arthritis, unspecified hip M06.861 Other specified rheumatoid arthritis, right knee M06.862 Other specified rheumatoid arthritis, left knee M06.869 Other specified rheumatoid arthritis, unspecified knee M06.871 Other specified rheumatoid arthritis, right ankle and foot M06.872 Other specified rheumatoid arthritis, left ankle and foot M06.879 Other specified rheumatoid arthritis, unspecified ankle and foot M06.88 Other specified rheumatoid arthritis, vertebrae M06.89 Other specified rheumatoid arthritis, multiple sites M06.9 Rheumatoid arthritis, unspecified M08.00 Unspecified juvenile rheumatoid arthritis of unspecified site M08.011 Unspecified juvenile rheumatoid arthritis, right shoulder M08.012 Unspecified juvenile rheumatoid arthritis, left shoulder M08.019 Unspecified juvenile rheumatoid arthritis, unspecified shoulder M08.021 Unspecified juvenile rheumatoid arthritis, right elbow M08.022 Unspecified juvenile rheumatoid arthritis, left elbow M08.029 Unspecified juvenile rheumatoid arthritis, unspecified elbow M08.031 Unspecified juvenile rheumatoid arthritis, right wrist M08.032 Unspecified juvenile rheumatoid arthritis, left wrist M08.039 Unspecified juvenile rheumatoid arthritis, unspecified wrist M08.041 Unspecified juvenile rheumatoid arthritis, right hand M08.042 Unspecified juvenile rheumatoid arthritis, left hand M08.049 Unspecified juvenile rheumatoid arthritis, unspecified hand M08.051 Unspecified juvenile rheumatoid arthritis, right hip M08.052 Unspecified juvenile rheumatoid arthritis, left hip M08.059 Unspecified juvenile rheumatoid arthritis, unspecified hip M08.061 Unspecified juvenile rheumatoid arthritis, right knee M08.062 Unspecified juvenile rheumatoid arthritis, left knee M08.069 Unspecified juvenile rheumatoid arthritis, unspecified knee M08.071 Unspecified juvenile rheumatoid arthritis, right ankle and foot M08.072 Unspecified juvenile rheumatoid arthritis, left ankle and foot M08.079 Unspecified juvenile rheumatoid arthritis, unspecified ankle and foot M08.08 Unspecified juvenile rheumatoid arthritis, vertebrae 7

M08.09 Unspecified juvenile rheumatoid arthritis, multiple sites M08.20 Juvenile rheumatoid arthritis with systemic onset, unspecified site M08.211 Juvenile rheumatoid arthritis with systemic onset, right shoulder M08.212 Juvenile rheumatoid arthritis with systemic onset, left shoulder M08.219 Juvenile rheumatoid arthritis with systemic onset, unspecified shoulder M08.221 Juvenile rheumatoid arthritis with systemic onset, right elbow M08.222 Juvenile rheumatoid arthritis with systemic onset, left elbow M08.229 Juvenile rheumatoid arthritis with systemic onset, unspecified elbow M08.231 Juvenile rheumatoid arthritis with systemic onset, right wrist M08.232 Juvenile rheumatoid arthritis with systemic onset, left wrist M08.239 Juvenile rheumatoid arthritis with systemic onset, unspecified wrist M08.241 Juvenile rheumatoid arthritis with systemic onset, right hand M08.242 Juvenile rheumatoid arthritis with systemic onset, left hand M08.249 Juvenile rheumatoid arthritis with systemic onset, unspecified hand M08.251 Juvenile rheumatoid arthritis with systemic onset, right hip M08.252 Juvenile rheumatoid arthritis with systemic onset, left hip M08.259 Juvenile rheumatoid arthritis with systemic onset, unspecified hip M08.261 Juvenile rheumatoid arthritis with systemic onset, right knee M08.262 Juvenile rheumatoid arthritis with systemic onset, left knee M08.269 Juvenile rheumatoid arthritis with systemic onset, unspecified knee M08.271 Juvenile rheumatoid arthritis with systemic onset, right ankle and foot M08.272 Juvenile rheumatoid arthritis with systemic onset, left ankle and foot M08.279 Juvenile rheumatoid arthritis with systemic onset, unspecified ankle and foot M08.28 Juvenile rheumatoid arthritis with systemic onset, vertebrae M08.29 Juvenile rheumatoid arthritis with systemic onset, multiple sites M08.3 Juvenile rheumatoid polyarthritis (seronegative) M08.40 Pauciarticular juvenile rheumatoid arthritis, unspecified site M08.411 Pauciarticular juvenile rheumatoid arthritis, right shoulder M08.412 Pauciarticular juvenile rheumatoid arthritis, left shoulder M08.419 Pauciarticular juvenile rheumatoid arthritis, unspecified shoulder M08.421 Pauciarticular juvenile rheumatoid arthritis, right elbow M08.422 Pauciarticular juvenile rheumatoid arthritis, left elbow M08.429 Pauciarticular juvenile rheumatoid arthritis, unspecified elbow M08.431 Pauciarticular juvenile rheumatoid arthritis, right wrist M08.432 Pauciarticular juvenile rheumatoid arthritis, left wrist M08.439 Pauciarticular juvenile rheumatoid arthritis, unspecified wrist M08.441 Pauciarticular juvenile rheumatoid arthritis, right hand M08.442 Pauciarticular juvenile rheumatoid arthritis, left hand M08.449 Pauciarticular juvenile rheumatoid arthritis, unspecified hand M08.451 Pauciarticular juvenile rheumatoid arthritis, right hip M08.452 Pauciarticular juvenile rheumatoid arthritis, left hip M08.459 Pauciarticular juvenile rheumatoid arthritis, unspecified hip M08.461 Pauciarticular juvenile rheumatoid arthritis, right knee M08.462 Pauciarticular juvenile rheumatoid arthritis, left knee M08.469 Pauciarticular juvenile rheumatoid arthritis, unspecified knee M08.471 Pauciarticular juvenile rheumatoid arthritis, right ankle and foot M08.472 Pauciarticular juvenile rheumatoid arthritis, left ankle and foot M08.479 Pauciarticular juvenile rheumatoid arthritis, unspecified ankle and foot M08.48 Pauciarticular juvenile rheumatoid arthritis, vertebrae M08.80 Other juvenile arthritis, unspecified site M08.811 Other juvenile arthritis, right shoulder 8

M08.812 Other juvenile arthritis, left shoulder M08.819 Other juvenile arthritis, unspecified shoulder M08.821 Other juvenile arthritis, right elbow M08.822 Other juvenile arthritis, left elbow M08.829 Other juvenile arthritis, unspecified elbow M08.831 Other juvenile arthritis, right wrist M08.832 Other juvenile arthritis, left wrist M08.839 Other juvenile arthritis, unspecified wrist M08.841 Other juvenile arthritis, right hand M08.842 Other juvenile arthritis, left hand M08.849 Other juvenile arthritis, unspecified hand M08.851 Other juvenile arthritis, right hip M08.852 Other juvenile arthritis, left hip M08.859 Other juvenile arthritis, unspecified hip M08.861 Other juvenile arthritis, right knee M08.862 Other juvenile arthritis, left knee M08.869 Other juvenile arthritis, unspecified knee M08.871 Other juvenile arthritis, right ankle and foot M08.872 Other juvenile arthritis, left ankle and foot M08.879 Other juvenile arthritis, unspecified ankle and foot M08.88 Other juvenile arthritis, other specified site M08.89 Other juvenile arthritis, multiple sites M08.90 Juvenile arthritis, unspecified, unspecified site M08.911 Juvenile arthritis, unspecified, right shoulder M08.912 Juvenile arthritis, unspecified, left shoulder M08.919 Juvenile arthritis, unspecified, unspecified shoulder M08.921 Juvenile arthritis, unspecified, right elbow M08.922 Juvenile arthritis, unspecified, left elbow M08.929 Juvenile arthritis, unspecified, unspecified elbow M08.931 Juvenile arthritis, unspecified, right wrist M08.932 Juvenile arthritis, unspecified, left wrist M08.939 Juvenile arthritis, unspecified, unspecified wrist M08.941 Juvenile arthritis, unspecified, right hand M08.942 Juvenile arthritis, unspecified, left hand M08.949 Juvenile arthritis, unspecified, unspecified hand M08.951 Juvenile arthritis, unspecified, right hip M08.952 Juvenile arthritis, unspecified, left hip M08.959 Juvenile arthritis, unspecified, unspecified hip M08.961 Juvenile arthritis, unspecified, right knee M08.962 Juvenile arthritis, unspecified, left knee M08.969 Juvenile arthritis, unspecified, unspecified knee M08.971 Juvenile arthritis, unspecified, right ankle and foot M08.972 Juvenile arthritis, unspecified, left ankle and foot M08.979 Juvenile arthritis, unspecified, unspecified ankle and foot M08.98 Juvenile arthritis, unspecified, vertebrae M08.99 Juvenile arthritis, unspecified, multiple sites Description Autoantibodies directed against cyclic citrullinated proteins (anti-ccp) are found in many patients with rheumatoid arthritis (RA). In patients with RA and active joint inflammation, levels of anti-ccp are higher 9

in the synovial fluid than in the peripheral circulation. Anti-CCP found in the serum is thought to be a result of diffusion of these antibodies from the synovial fluid into the general circulation. Autoantibodies against CCP have been recognized and measured for several decades.. However, older tests were performed by a cumbersome immunofluorescence assay and were not commonly used in routine clinical practice. Therefore, attention turned toward measuring anti-ccp antibodies. Serum anti- CCP levels are currently measured using an ELISA assay. Examples of anti-ccp testing for RA include the QUANTA Lite CCP IgG ELISA from INOVA Diagnostics and the Diastat anti-ccp ELISA test from Axis-Shield Diagnostics All anti-ccp tests for RA are considered investigational regardless of the commercial name, the manufacturer or FDA approval status except when used for the medically necessary indications that are consistent with the policy statement. Summary Extensive evidence has established that anti-ccp has a moderately high sensitivity, a high specificity, and is a strong predictor of future erosive arthritis. The test is useful in confirming the diagnosis of RA in patients with early disease, especially when the criteria for a diagnosis of RA are not met by other clinical or laboratory measures. Early identification of patients with RA is important since timely treatment with DMARDs can prevent progression of destructive arthritis and improve functional status. The extensive evidence of the usefulness of the test for diagnosing RA supports its medically necessary designation. The evidence suggests that anti-ccp is not useful as a measure of disease activity and/or response to treatment. As a result, the use of anti-ccp is considered investigational for monitoring disease activity in RA. Policy History Date Action 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 11/2011- Medical policy ICD 10 remediation: Formatting, editing and coding updates. 4/2012 No changes to policy statements. 6/2011 Reviewed - Medical Policy Group Orthopedics, Rehabilitation Medicine and Rheumatology. No changes to policy statements. 7/2010 Reviewed - Medical Policy Group Orthopedics, Rehabilitation Medicine and Rheumatology.No changes to policy statements. 11/01/09 Medical Policy 142 effective 11/01/09 created. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References 1. Arnett FC, Edworthy SM, Bloch DA et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31(3):315-24. 2. Kaarela K, Kauppi MJ, Lehtinen KE. The value of the ACR 1987 criteria in very early rheumatoid arthritis. Scand J Rheumatol 1995; 24(5):279-81. 10

3. Saraux A, Berthelot JM, Chales G et al. Ability of the American College of Rheumatology 1987 criteria to predict rheumatoid arthritis in patients with early arthritis and classification of these patients two years later. Arthritis Rheum 2001; 44(11):2485-91. 4. Visser H, le Cessie S, Vos K et al. How to diagnose rheumatoid arthritis early: a prediction model for persistent (erosive) arthritis. Arthritis Rheum 2002; 46(2):357-65. 5. Aletaha D, Neogi T, Silman AJ et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2010; 69(9):1580-8. 6. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002; 46(2):328-46. 7. Whiting PF, Smidt N, Sterne JA et al. Systematic review: accuracy of anti-citrullinated Peptide antibodies for diagnosing rheumatoid arthritis. Ann Intern Med 2010; 152(7):456-64; W155-66. 8. Avouac J, Gossec L, Dougados M. Diagnostic and predictive value of anti-cyclic citrullinated protein antibodies in rheumatoid arthritis: a systematic literature review. Ann Rheum Dis 2006; 65(7):845-51. 9. Qin X, Deng Y, Xu J et al. Meta-analysis: diagnostic value of serum anti-mutated citrullinated vimentin antibodies in patients with rheumatoid arthritis. Rheumatol Int 2011; 31(6):785-94. 10. Syversen SW, Gaarder PI, Goll GL et al. High anti-cyclic citrullinated peptide levels and an algorithm of four variables predict radiographic progression in patients with rheumatoid arthritis: results from a 10-year longitudinal study. Ann Rheum Dis 2008; 67(2):212-7. 11. Bukhari M, Thomson W, Naseem H et al. The performance of anti-cyclic citrullinated peptide antibodies in predicting the severity of radiologic damage in inflammatory polyarthritis: results from the Norfolk Arthritis Register. Arthritis Rheum 2007; 56(9):2929-35. 12. Yamane T, Hashiramoto A, Tanaka Y et al. Easy and accurate diagnosis of rheumatoid arthritis using anti-cyclic citrullinated peptide 2 antibody, swollen joint count, and C-reactive protein/rheumatoid factor. J Rheumatol 2008; 35(3):414-20. 13. Wagner E, Skoumal M, Bayer PM et al. Antibody against mutated citrullinated vimentin: a new sensitive marker in the diagnosis of rheumatoid arthritis. Rheumatol Int 2009; 29(11):1315-21. 14. Shidara K, Inoue E, Tanaka E et al. Comparison of the second and third generation anti-cyclic citrullinated peptide antibody assays in the diagnosis of Japanese patients with rheumatoid arthritis. Rheumatol Int 2011; 31(5):617-22. 15. Ryu HJ, Takeuchi F, Kuwata S et al. The diagnostic utilities of anti-agalactosyl IgG antibodies, anticyclic citrullinated peptide antibodies, and rheumatoid factors in rheumatoid arthritis. Rheumatol Int 2011; 31(3):315-9. 16. Hwang SM, Kim JO, Yoo YM et al. Performance analysis of the ARCHITECT anti-cyclic citrullinated peptide antibody in the diagnosis of rheumatoid arthritis. Clin Chem Lab Med 2010; 48(2):225-30. 17. Bongi SM, Manetti R, Melchiorre D et al. Anti-cyclic citrullinated peptide antibodies are highly associated with severe bone lesions in rheumatoid arthritis anti-ccp and bone damage in RA. Autoimmunity 2004; 37(6-7):495-501. 18. Raza K, Breese M, Nightingale P et al. Predictive value of antibodies to cyclic citrullinated peptide in patients with very early inflammatory arthritis. J Rheumatol 2005; 32(2):231-8. 19. Landmann T, Kehl G, Bergner R. The continuous measurement of anti-ccp-antibodies does not help to evaluate the disease activity in anti-ccp-antibody-positive patients with rheumatoid arthritis. Clin Rheumatol 2010; 29(12):1449-53. 20. Zendman AJ, van Venrooij WJ, Pruijn GJ. Use and significance of anti-ccp autoantibodies in rheumatoid arthritis. Rheumatology (Oxford) 2006; 45(1):20-5. 21. Ronnelid J, Wick MC, Lampa J et al. Longitudinal analysis of citrullinated protein/peptide antibodies (anti-cp) during 5 year follow up in early rheumatoid arthritis: anti-cp status predicts worse disease activity and greater radiological progression. Ann Rheum Dis 2005; 64(12):1744-9. 22. Dejaco C, Duftner C, Klotz W et al. Third generation anti-cyclic citrullinated peptide antibodies do not predict anti-tnf-alpha treatment response in rheumatoid arthritis. Rheumatol Int 2010; 30(4):451-4. 23. National Collaborating Centre for Chronic Conditions. Rheumatoid Arthritis: the management of rheumatoid arthritis in adults. National Institute for Health and Clinical Excellence (NICE) 2009; Feb 35p. (NICE clinical guideline no 79). 11